Medically Unexplained Symptoms

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Medically Unexplained Symptoms
Amanda Howe MA MEd MD FRCGP Professor of Primary
Care University of East Anglia, Norwich, U.K.
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MUS

• patients who present in primary care with a
  variety of physical symptoms, for whom we find it
  difficult to arrive at a clear diagnosis
• a challenge / threat to the doctor?
• Spectrum of presentations linked with
• Some frequent attenders / heart sink
• Functional disorders symptoms best explained by
  abnormalities of function, in the absence of
  disease
• Physical presentations of anxiety and / or
  depression
• Somatisation the physical presentation of
  psychological distress
• Somatoform disorders
• Approaches relate to consultation skills /
  reattribution

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What do we already know?

• How are symptoms caused?
• What are the underlying physiological mechanisms?
  
• Give examples of physical conditions known to be
  influenced by psychological states
• How do we learn to understand our experiences?
• What is the role of health beliefs in illness
  experience?
• How do patients present distress to clinicians?

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Some more questions...

1. What proportion of people have significant
   psychological distress when they consult in a UK
   primary care population?
2. How do sociodemographic factors influence
   presentation and diagnosis?
3. What are the difficulties of discussing the mind
   body continuum with patients?
4. What are the difficulties of conceptualising the
   mind body continuum anyway?
5. Or is it a mind body split?! .....

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Context

• 1 in 4 5 people consulting are significantly
  more psychologically distressed than the
  population norm
• Based on match of views with measures e.g. GHQ
• High and low pickup by clinicians appears
  based on their consultation style and ?? beliefs
  / expectations
• Detection and discussion of psychological aspects
  commoner if -gt
• Clinical antennae are working
• Patients themselves raise emotions /
  psychological aspects
• Women gt men, life events gt none, midlife gt older
  / young
• Varying cultural expectations (on both sides)

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Consulting across the body mind divide some
(contestable) claims

• All experiences have psychological aspects
• All illnesses have a psychological impact,
  because illness is a threat to self
• Symptoms common (iceberg), often unexplained
• Cultural awareness and acceptance of the mind
  body are conditioned through emotional
  expressiveness and insight
• Insight into, knowledge of, and effective coping
  responses for illhealth are useful adaptive
  mechanisms for us all
• Effective intra and interpersonal communication
  is essential to dealing with illness effectively,
  both for management AND diagnosis
• Doing this well involves skills and attitudes as
  well as knowledge

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What patient features are known to be associated
with MUS?

• Adverse social circumstances
• Anxious reaction
• Hyperattention to symptoms
• Difficulty expressing feelings
• Poor peer relationships
• Previous illness prolonged
• Other behavioural or functional problems
• Intermittent or atypical pattern
• Minor physical signs

• Learned behaviour
• Psychological gain
• Emotional gain
• Attention seeking
• Introversion
• Excessive sensitivity to physical sensation
• Anxiety / depression
• Previous illness and lack of care increase
  dysfunctional response to adversity

School of Medicine, Health Policy and Practice
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Why do patients differ in their experience and
expression of symptoms?

• Children learn from the relationship between
  their own behaviours and the responses of others
• the early mother - infant relationship as a
  homeostatic regulatory system that facilitates
  the emergence of a primitive mind from the bodily
  functions of the infant (Mahler, 1972)1
• Move over time from external to internal
  regulation, with development of independence
• Loss/separation always a threat to self identity
• Link to MUS constitutional and learned ways of
  dealing with emotion, embodied through
  neurophysiological pathways

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Factors influencing this pathway
Genetic / constitutional factors
Home / child rearing

Developmental stage
Socioeconomic factors
Life events
Significant others
Cultural and social environment
School of Medicine, Health Policy and Practice
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Explanatory concepts - self esteem, coping and
resilience

• Psychological resilience the ability to adjust
  successfully to major life changes a stable
  personality trait that minimises negative effects
  of stress and promotes adaptation2
• Coping mechanisms3 cognitive and emotional
  appraisal rethinking the problem, reconsidering
  your reactions
• Extroversion (expression of feelings) - linked
  with less physical symptoms and better sense of
  wellbeing - the correlation between potential
  health problems and inhibition of behaviour and
  emotional expression is seen by the (age of) 2
  years old4
• Self esteem dependent on successful attachments
• Constructive psychological approaches in adult
  life are correlated with stable caring
  relationships in childhood, and weakened by
  disruptions in emotional security

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Consulting with patients with MUS

• Key components to detecting
• Consultation skills
• Establishing a rapport
• Open questions
• Cueing
• Exploring ideas, concerns and expectations (ICE)
• Checking understanding
• Full history and examination

• Key components to managing
• Respect and acceptance
• Time
• Choices
• Focused explanation
• Linking mind and body reattribution
• Clear expectations of next steps
• Multilevel management

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Reattribution

• Four crucial stages in the consultation process
• Feeling understood The general practitioner
  elicits a history of the physical symptoms,
  explores the patients beliefs about these
  symptoms and associated psychosocial and
  lifestyle factors, and makes a brief focussed
  physical examination
• Broadening the agenda beyond the presenting
  physical symptoms. The doctor feeds back the
  results of the examination and any recent
  investigations, and explains the lack of serious
  underlying pathology. The doctor explicitly
  acknowledges the reality of the patients
  physical symptoms, and explores the extent of the
  patients acceptance that psychosocial or
  lifestyle factors may be inked to these symptoms
• Making the link The doctor links the physical
  symptoms to an underlying psychosocial or
  lifestyle explanation, using physiological and/or
  temporal links that are compatible with the
  patients symptom beliefs
• Negotiation over further management. Various,
  including exploring patients views about
  treatment, promoting problem solving and coping
  strategies, appropriate use of relaxation,
  appropriate treatment for depression, and
  agreeing specific plans for follow-up.

School of Medicine, Health Policy and Practice
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Challenges

• Maintaining a positive therapeutic relationship
• Keeping continuity
• Pursuing a dual agenda
• Containing anxiety / referrals
• Time management
• Threat to self perception for doctor and patient
• Early preventive interventions
• Population perspective
• Media perspective
• Cultural variations

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Implications

• For the practice case discussion, attendance
  audits, true picture of all health care inputs
• For the practitioner further training,
  appropriate use of time and resources, reflection
  and psychological insight
• For the service collective approach, simple
  psychological therapies, liaison psychiatry
• For society therapeutic support in early years,
  psychological health, self help
• For cross cultural situations
• Other ........

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Medically Unexplained Symptoms
Amanda Howe MA MEd MD FRCGP Professor of Primary
Care University of East Anglia, Norwich, U.K.